Preoperative Medical Care of the Surgical Patient Byron Turkett, PA-C, MPAS Chief PA, Division of Trauma/Critical Care University of Tennessee Medical Center Knoxville
UTMCK
Introduction • “A chance to cut is a chance to cure” • “Nothing heals like cold, hard steel” • Surgery = stress and insults – Physiology of surgery – Maximize pre-operative condition of patient – Preoperative evaluation: H&P – Perioperative care: think of what can kill first...
UTMCK
UTMCK
Perioperative medical care: • • • • • • • • •
Surgical emergency Cardiac disease Pulmonary disease Renal dysfunction Liver dysfunction Diabetics Bleeding disorders Malnourished Pregnancy UTMCK
Perioperative medical care: • Surgical emergency – Trauma
• • • • • • • •
Cardiac disease Pulmonary disease Renal dysfunction Liver dysfunction Diabetics Bleeding disorders Malnourished Pregnancy UTMCK
Surgical Emergency • 76 yo WM “coded” in front of HLVI building; ACLS followed x 20 min with intermittent pulse return; intubated, IVs placed, brought to ER; SBP 60 with HR return • MICU team called to eval; pt started on Neo-synephrine for bp • Surgery called when Hct returned 14.2 UTMCK
Surgical Emergency • What do you want to do? • HISTORY
& PHYSICAL
• History? (tailor to situation) • VS 70/20 135 16 (IMV) 36.4 • “Pt is unconscious, intubated, not moving - abdomen is very distended, quiet BS”
• Keep DDx in mind during H&P • Why can’t he keep a bp?
• What do you want to do about it? •Risk of doing something vs. risk of doing nothing?
• What do you need to do before surgery? UTMCK
Surgical Emergency • AMPLE history – A llergies – M edications – Past medical history – Last meal – E vents preceding the surgery
UTMCK
UTMCK
UTMCK
44 yo WF who presented to ER today with RUQ three days ago. RUQ U/S showed gallstones. CT scan of the abdomen/pelvis showed gallstones.
UTMCK
“Pre-op this patient” • • • • • • • • •
History and physical Informed consent for operation and blood Type and screen or type and cross CXR (age greater than 20) 12-lead ECG (age greater than 40) BMP, M/P, CBC, PT, PTT, INR NPO after MN (IV Fluids) Pre-op Note Pre-op Orders (hep 5000 units SQ, Abx, beta blocker) • ?Bowel Prep UTMCK
Pre-Op Labs and Studies • CBC – Anemia – Malignancy – Renal Disease – Cardiac Disease – Pregnancy
UTMCK
Pre-Op Labs and Studies • Chemistry – Diabetes – HTN – CVD – Renal Disease – Liver Disease – Diuretic Use – Elderly UTMCK
Pre-Op Labs and Studies • UA – Rarely Needed, only if symptomatic
• CXR – Rarely indicated as screening tool
• EKG – – –
Males >40, Females >50 ?baseline History of CVD, DM. HTN Planned thoracic, aortic, intraperitoneal or emergency surgery UTMCK
Symptomatic Cardiac Disease Work Up • • • • • • • •
History of event Physical exam 12-Lead ECG CXR ABG Cardiac Panel BMP, M/P, CBC, PT, PTT, INR Chart Review UTMCK
Finding Cardiac Disease in the Asymptomatic Patient • • • • • • • •
Abnormal vital signs Assess functional status Tachycardia JVD at 30 degrees Bruits Pedal Edema Rubs and 3rd heart sounds Murmurs – Most apical systolic murmurs are innocent – Any murmur with a thrill or any diastolic are NOT innocent UTMCK
Cardiac disease in peri-op period MI
arrhythmias
CHF
• CAD can cause any of these • Risks for CAD:
XX
– age, sex, HTN, XOL, DM, tobacco
• Modify those risk factors you can... medical therapy
will cover later. . . UTMCK
Coronary Artery Disease •
Definition of CAD....
• Physiology of surgery: – ↑ myocardial oxygen demand – ↑ catecholamines: ↑ HR, ↑ contractility, ↑PVR – ↑ HR also causes decreased diastolic filling • Coronary arteries fill in diastole • Less blood flowing in coronaries: less myocardial O2 supply UTMCK
Myocardial Infarction • Pt without risks has 0.5% chance of MI – Pt with risks has 5% chance of perioperative MI
• Perioperative MI has 17-41% mortality • CAD causes MI....look at PMH • Risk stratifications: MI w/in 3 months of OR
27% reinfarction rate
MI 3-6 months before OR
10% reinfarction rate
MI >6 months of OR
5-8% reinfarction rate*
UTMCK
Prevention of perioperative cardiac events 1) Wait 6 months if possible 2) Beta-blockade* • • • •
200 pts with CAD or risk factors for CAD atenolol pre-op and peri-op in ½ MI reduced 50% in first 48h 2 year mortality 10% vs 21%
3) Maintain peri-operative normothermia •
↓ cardiac events, esp. arrhythmias
4) Treat peri-operative hypertension * Mangano NEJM 335:1713, 1996.
UTMCK
Prevention of perioperative cardiac events 7) Watch for and treat arrhythmias
Causes?
Drugs, electrolytes, ischemia, fluid shifts, body T
Treatment?
underlying cause, rate control, conversion
UTMCK
Perioperative medical care: • • • • • • • • •
Surgical emergency Cardiac disease Pulmonary disease Renal dysfunction Liver dysfunction Diabetics Bleeding disorders Malnourished Pregnancy UTMCK
Pulmonary disease • Patient-related risks – Chronic lung dz – wheeze, productive cough – Smoking – General health – Obesity – Age? • separate from others?
UTMCK
Pulmonary Disease • Procedure related risks – Type of anesthesia • GETA alone ↓ FRC 11% • inhibited cough/mucociliary function
– Surgical site • Increased with midline incision or dissection of upper abdomen and with thoracotomy
– Duration of surgery • Longer duration of GETA increases risk of pulmonary complications • V/Q mismatching due to positioning UTMCK
Modifiable Pulmonary Risks • Obstruction to flow – COPD – Asthma
• Obesity physiology – – –
↓ lung capacity, FRC, VC ↑ WOB, ATX, Secretions hypoxemia
• Tobacco – Rel Risk 2-6x > vs Non Smoker – Definition of “stopped smoking”.... – “When was your last cigarette?” UTMCK
Pre-operative risk assessment: pulmonary function • Patient history – Functional Status – Unexplained dyspnea, cough, reduced exercise tolerance, OSA
• Physical exam: – Wheeze, rales, rhonchi, ↑ exp time, ↓ BS, loose rattle w/forced cough (can reveal underlying pathology) – 5.8x more likely to develop pulmonary complications* – FEV1 Screening
• Pre-operative CXR over 40, without a baseline should be considered • ABG – No role for routine use * Lawrence et al Chest 110:744, 1996
UTMCK
Perioperative medical care: • • • •
Surgical emergency Cardiac disease Pulmonary disease Renal dysfunction – Dialysis dependent
• • • • •
Liver dysfunction Diabetics Bleeding disorders Malnourished Pregnancy UTMCK
Renal Dysfunction • • • •
Not all renal failure is oliguric H&P Check BUN/Cr, CBC Assume DM have CRI – Volume status • Overload and hypotension are common
– Electrolytes.....sequelae? • Watch K, Ca, Mag, Phos, HCO3
• Drug metabolism – Be aware of nephrotoxic agents – CAUTION w/Succinylcholine UTMCK
Renal dysfunction • Dialyze preop to improve electrolytes, volume status • No K+ in MIVF • Very judicious MIVF while NPO • Altered drug metabolism • Altered platelet fxn UTMCK
Perioperative medical care: • • • • • • • • •
Surgical emergency Cardiac disease Pulmonary disease Renal dysfunction Liver dysfunction Diabetics Bleeding disorders Malnourished Pregnancy
Why does hepatic disease cause coagulopathy?
UTMCK
Child-Pugh Criteria for Hepatic Reserve Measure
A
B
C
Bilirubin
3.0
Albumin
>3.5
2.8-3.5
6
None
Slight
Moderate
Neuro
None
Minimal
“Coma”
Mortality